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Full text of "United States Navy Medical News Letter Vol. 33 No. 2, 23 January 1959"

NavMed 369 



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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 33 



Friday, 23 January 1959 



No. 2 



TABLE OF CONTENTS 



i 



Pneumococcal Endocarditis 2 

Bronchogenic Carcinoma 4 

Pulmonary Infiltration 7 

Cardiac Asthma 10 

Acute Venous Thrombosis 12 

Benign Disease of the Uterine Fundus 16 

Patella in Degenerative Joint Disease 18 

Broncho -Pulmonary Amoebiasis 19 

Teflon (Tetrafluoroethylene Resin) 21 

-* Beryllium and Berylliosis 23 

Cataracts and Ultra High Frequency Radiation 25 

Prolonged and Recurrent Industrial Dermatitis 27 

i Noise - Is It a Health Problem? 27 

New Convening Dates for Pest Control Course 28 

Aviation Seminar 29 

Board Certifications 29 

From the Note Book 30 

UN MEMORJAM 31 

Recent Research Reports 32 

DENTAL SECTION 

DC Feature in January Journal . .34 Information from Essayists 35 

ADA Relief Fund Reaches $63, 695 35 

RESERVE SECTION 

Tropical Medicine in the Field . . 36 Credit for Residency Training. . . 37 

PREVENTIVE MEDICINE SECTION 

DDT Resistance in the Human Body Louse 37 



Medical News Letter, Vol. 33, No. 2 



Pneumococcal Endocarditis 



Pneumococcal endocarditis is a septic complication of acute pneumo- 
coccal infections — most commonly pneumococcal pneumonia. The introduc- 
tion of antimicrobial agents of both synthetic and natural origin during the 
past 20 years has been responsible for a dramatic reduction in mortality 
from the pneumonccoccal pneumonias; also, these agents have reduced the 
incidence of purulent complications of these pneumonias and, in many in- 
stances, have been responsible for the cure of complications which at one 
time were considered almost universally fatal. In view of the fact that agents 
are available for the treatment of such complications, a review of the litera- 
ture on pneumococcal endocarditis wasmade in the hope that a better apprec- 
iation of the clinical features of the disease entity might be made available, 
thereby permitting therapy to be instituted earlier. 

Pneumococcal endocarditis has been reported among all age groups. 
While there have been several case reports of patients in their first as well 
as ninth decades, the median age incidence lies in the fifth decade. Neither 
sex nor race seems to have a predisposing influence on the incidence of 
pneumococcal endocarditis. The complication was noted much oftener in 
males than in females, but likewise the primary disease, pneumococcal pneu- 
monia, is seen more frequently in males. Similarly, pneumonia is seen in 
large hospitals of the north temperate zone more often in Negroes, although 
the incidence of endocarditis is no greater among Negroes than among white 
pneumonia patients. 

"While pneumococcal endocarditis may follow any primary pneumo- 
coccal infection, the overwhelming majority of reported cases followed pneumo- 
coccal pneumonia, usually of the classical lobar type. Less frequently, the 
pneumonia was of the lobular type or may have been diagnosed only at necropsy. 
Ln the rare instance, the portal of entry was difficult to ascertain; endocarditis 
due to a pneumococcus has been reported to follow meningitis, mastoiditis, 
tooth extraction, septic abortion, urethral dilatation, and surgical intervention 
for various conditions. 

That antecedent disease of the valvular endocardium predisposes to 
attack by the pneumococcus is doubtful. In the present series of cases col- 
lected from the literature, a history of rheumatic heart disease or physical 
signs of valvular damage was noted in less than 10% of cases. On the other 
hand, many more cases were shown at necropsy to have histological stigmata 
of rheumatic fever. It may be safely concluded that there does not appear to 
be nearly so great, a predisposition of antecedent valvular damage to attack 
by the pneumococcus as has been shown to be true in the case of Strepto- 
coccus viridans and related groups of streptococci. "While an occasional case 
of pneumococcal endocarditis has been reported as being engrafted on a valve 
damaged by syphilis, this complication happens rarely. 

In view of the fact that more than 90% of the cases of pneumococcal 
endocarditis represent complications of pneumococcal pneumonia, the clinical 



Medical News Letter, Vol. 33, No. 2 



picture of the complication may be completely masked by the primary 
disease. While classical pneumococcal pneumonia may affect people of all 
ages, endocarditis is primarily a complication affecting patients of middle 
age and older. The complication is frequently' ushered in by a sudden chill 
early in convalescence at which time relapse, recrudescence, or inadequate 
therapy may offer a plausible explanation to the physician for the chill and 
subsequent fever. At other times, the complication apparently has its onset 
in the febrile course of the patient and may thereby escape detection. In 
another group of patients, the onset of the endocarditis came late in the 
course of the disease or even after recovery from a presumably trivial res- 
piratory infection; during the era of serum therapy, the exacerbation of fever 
frequently required differentiation from serum sickness as an explanation 
therefor, 

Although the patient may satisfactorily tolerate the chill and subsequent 
fever, there is usually an increase in the anxious appearance of the patient 
with an endocardial complication of pneumonia. Frequently, the evidence of 
increased toxemia is the principal sign to alert the physician to the diagnosis 
when no localizing signs are present. 

The course of patients with pneumococcal endocarditis is usually one 
leading to a rapidly fatal outcome. These patients usually become increas- 
ingly toxic and succumb either to toxemia or meningitis. Some expire be- 
cause of cardiac failure secondary to deformity or rupture of a valve cusp. 
The duration of the disease varies considerably even in untreated patients. 
It is difficult to ascertain the precise onset of the endocarditis, especially 
in patients whose endocardial lesion merges with the primary pulmonary 
disease. As a rule, these patients do not survive longer than 6 weeks; notable 
exceptions to this survival period have been reported. 

Therefore, it may be said that the diagnosis of pneumococcal endocar- 
ditis must be based primarily on a high degree of suspicion. The persistence 
of pneumococcemia or the recurrence of a positive blood culture of the pneumo- 
coccus in a patient receiving antimicrobial therapy directed at this organism 
should alert the physician to the possibility that endocarditis may be present. 
If laboratory facilities are available which detect not only the pr.eumococcus 
but also simultaneous circulating type -specific antibodies, the suspicion 
should certainly be increased; this is especially true when no other pyemic 
focus can be ascertained. Moreover, if embolic phenomena occur in the 
course of the patient's illness, the likelihood of endocarditis is increased. 
When heart murmurs develop or change in intensity — especially those heard 
in diastole — they can usually be ascribed to endocarditis in the face of a per- 
sisting pneumococcemia. 

Pneumococcal endocarditis remains a complication of serious prognostic 
import. Inasmuch as it may occur in patients with previously undamaged 
valves, every pneumococcal infection should be treated vigorously and early 
with the aim of preventing endocardial complications. (Ruegsegger, J. M. , 
Pneumococcal Endocarditis: Am. Heart J., 56: 867-875, December 1958) 



Medical News Letter, Vol. 33, No. 2 



Bronchogenic Carcinoma 



Although many studies have been made and figures compiled of broncho- 
genic carcinoma, relatively few concerning the individual cell type have been 
reported. In the treatment of most tumors, one of the factors concerning 
the ultimate prognosis of the disease is its cell type. With bronchogenic car- 
cinoma, however, the studies concerning individual cell types — although rel- 
atively few — have been largely controversial. 

Many authors hold the view that the cell type is a highly valuable prog- 
nostic element. Others have reported that the individual cell type has no 
prognostic significance. Although at present there appears to be more evi- 
dence favoring a varied clinical course dependent on the different cell types, 
it is readily apparent that there is no complete agreement on this point. This 
study is concerned with this problem of correlating the clinicopathologic 
features of the various cell types. 

The clinical material was composed of all histologically proved cases 
of bronchogenic carcinoma treated at the Johns Hopkins Hospital, 1942 through 
1951. No patient after 1951 was included in order to insure that all patients 
would have been followed at least 5 years. The histologic material from 
these patients was from either surgical or autopsy specimens. The clinical 
records were studied and the data recorded. Separately, and without know- 
ledge of the clinical history, all histologic specimens were examined and 
the cell type was determined. As far as could be ascertained, all cases in 
which there was another primary cancer were eliminated in order to prevent 
including metastatic tumors of the lung. 

During this 10-year period, there were 351 histologically proved cases 
of bronchogenic carcinoma. Histologic diagnosis was made from tissue 
taken at thoracotomy alone in 126 cases. In 64 cases the diagnosis was 
made histologically at autopsy, and in 56 cases the diagnosis was made from 
material obtained at bronchoscopy. There were 43 cases diagnosed from 
lymph node biopsy and 5 from cell block study only. The remaining 57 cases 
were diagnosed by combinations of the above methods. Histologic material 
in some cases was limited to cytologic studies and bronchoscope biopsies 
both of which occasionally were inadequate to make a cell-type diagnosis, 
and no diagnosis other than bronchogenic carcinoma could be made. In other 
instances — even in resection cases — no diagnosis of cell type could be made 
with any degree of accuracy because of lack of a definite cellular pattern. 
These cases made up a group of 18 (5%). The remaining 333 cases (95%) 
were diagnosed as to distinct cell type. 

Admittedly, it is difficult to classify various histologic patterns in any 
tumor, and indeed, in many instances it is entirely unwarranted. One defin- 
itely should not try to force any tumor into a certain classification for the 
sole purpose of classification. There are many tumors which cannot be 
classified as to specific cell type with any degree of reliability; continual 
subgrouping or subclassification adds nothing of value, serving only to make 



Medical News Letter, Vol. 33, No. 2 



the issue more confusing and less accurate. However, most tumors in 
this study (95%) were of a predominant cell type. These cellular patterns 
are squamous -cell carcinoma, adenocarcinoma, and small-cell and large- 
undifferentiated-cell types. 

Of the 333 histologically typed cases out of the 351 in the present 
study, 127 patients received no surgical therapy. Most of the patients 
had evidence of metastases and their tumors were clearly inoperable; a few 
had other unrelated conditions of such a severe nature that operative therapy 
was thought to be unwise; a few patients refused surgical treatment. There 
were 206 patients who underwent thoracotomy, but only 107 had some type 
of resection. Therefore, although the operability rate was 62%, the re sec - 
tability rate dropped to 32%. 

Striking differences existed in the ability to treat patients having the 
various cell types. There were 111 patients with squamous -cell carcinoma 
who underwent thoracotomy; of these, 71 had resectable tumor. This was an 
operability rate of 74% and a resectability rate of 47%. There were 11 pal- 
liative resections, and 60 resections were done with the idea of curing the 
patient. Of the 40 patients with adenocarcinoma, 16 had inoperable lesions. 
In the remaining 24, the tumors were operable but only 11 were resectable. 
Of these resections, 1 was palliative and the other 10 were done as a curative 
measure. This gives an operability rate of 60% and a resectability rate of 
28%. Of the 95 patients with large -cell carcinoma, 44 had inoperable tumors. 
The remaining 51 tumors were operable, 23 being resectable. This was an 
operability rate of 54% and a resectability rate of 24%. Less than one -half 
of the patients with the small-cell type had operable carcinoma, only 20 out 
of 48 having had thoracotomy. Of these, only 2 had resections. This was 
an operability rate of 42%, but a resectability rate of only 4%. Thus, at one 
extreme, the squamous -cell type was resectable in 47%, whereas, at the 
other extreme, the small-cell type was resectable in only 4%. Of the patients 
with resections, the hilar lymph nodes contained tumor in these percentages: 
squamous-cell carcinoma, 27; small-cell carcinoma, 50; adenocarcinoma, 55; 
and large-cell carcinoma, 56. 

Follow-up data on all patients in this study were complete in 95%; there 
was a 99% follow-up of the patients who had had resection. Nineteen patients 
survived 5 years or longer after resection. This is an over all survival rate 
of 6% of all patients entering the hospital and a survival rate of 18% of all 
patients undergoing resection. 

It is obvious that information compiled from a group of patients having 
a tumor of a specific cell type cannot be directly applied to any one given 
patient with a tumor of the same cell type. The fact remains that in any given 
patient the factors of importance are the exact location of the tumor and to 
what extent and by what route spread has occurred. Therefore, to conclude 
that, because the patient has a particular type of tumor, his prognosis will be 
the same as that for the group is not sound. However, it can be stated that 
the course of the various cell types tends to fall into a more or less definite 



Medical News Letter, Vol. 33, No. 2 



pattern which gives valuable information. Thus, in dealing with a patient 
having a small-round-cell carcinoma there is very little chance of effecting 
a permanent cure. In this group, not a single patient was cured. On the 
other hand, in dealing with a patient having squamous -cell carcinoma, the 
chances are much more favorable — considering that 10% of all patients who 
entered the hospital with this type of cancer and 27% of those who left the 
hospital after resection survived 5 years or longer. Between these two 
extremes in prognosis are patients with adenocarcinoma and the large-cell 
type. 

This fact does not mean that the patient with the small-cell type should 
not be operated upon if there are no surgical indications of inoperability; how- 
ever, because of its location and rapid growth and spread, very few of such 
tumors will be resectable at the time of operation. In this study, only 4% 
of all tumors of this type were resectable. These statistics do not indicate 
that the small-cell type of carcinoma having a favorable location should not 
be resected, but rather point out that the chance of finding a favorable lesion 
in these cases is extremely small and that any heroic measure to attempt a 
cure in patients with this type of tumor is probably useless. On the other 
hand, not all patients with squamous-cell carcinoma will have a resectable 
tumor, but the chance of finding a favorable lesion is relatively good because 
almost one-half of the patients entering the hospital with this cell type of 
tumor were able to have re sectional therapy. More of the patients with 
adenocarcinoma and the large -cell types of tumor will be cured than those 
with the small-cell type. However, even in these groups there is a consid- 
erably lower percentage surviving than in the group of patients with squamous- 
cell carcinoma. It would, therefore, appear that prognosis cannot be founded 
on the cell type alone, but that the cell type is one important factor in the 
prognosis because it determines to a large extent the location, rate of growth 
and spread and, therefore, resectability and cure. (Collins, N. P. , Broncho- 
genic Carcinoma - Importance of the Cell Type: Arch Surg., 77: 925-932, 
December 1958) 

$ %s ;Js jj: $ sjs 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses. 

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Medical News Letter, Vol. 33, No. 2 



Pulmonary Infiltration 

The significance o£ roentgenographically unchanging pulmonary lesions, 
in the absence of bacteriologic or pathologic proof of etiology, is difficult 
to determine. It has been shown by Britten that many such cases subsequent- 
ly develop tuberculosis. The problem of the diagnosis of these cases is of 
special importance to the Armed Forces where intimate environmental 
situations exist. Therefore, it became necessary to assess accurately the 
risk of such persons developing active pulmonary tuberculosis and thereby 
becoming sources of infection. 

The purpose of this study was to measure the risk among military per- 
sonnel retained on active duty after clinical study had rendered diagnoses 
of "infiltration, pulmonary, cause undetermined" or "fibrosis, pulmonary, 
cause undetermined. " These two diagnoses were established in 1948 by a 
Joint Armed Forces decision in order to afford an orderly classification of 
unchanging, predominantly non-calcified pulmonary lesions of unknown etiology. 

A study group consisting of personnel with the above diagnoses and a con- 
trol group consisting of personnel diagnosed as having "hemorrhoids" were 
utilized to determine the risk of tuberculous infection in the two groups, i. e. , 
the incidence rates of tuberculosis. 

Both the study and control groups consisted of active duty Naval and 
Marine Corps personnel who had been admitted to naval medical facilities, 
clinically studied, and returned to duty during 1951. In order to make the 
results of the study meaningful, all cases who had had a diagnosis of active 
tuberculosis during or prior to 1951 were excluded. Also, to determine how 
many of the remaining personnel developed pulmonary tuberculosis between 
1952 and the end of 1954, all cases were excluded who had left the service 
during 1951 for any reason, e, g. , release from active duty, discharge for 
medical reasons, or death. 

There were 268 cases with the diagnosis of "infiltration, pulmonary, 
cause undetermined" or "fibrosis, pulmonary, cause undetermined" who met 
the above criteria and were, therefore, included in the study group. The 
control group consisted of 493 Naval and Marine Corps personnel, also meeting 
the above criteria who were admitted and returned to duty in 1951 with the diag- 
nosis of "hemorrhoids. " Members of the control group were selected by means 
of systematic sampling of the 3436 such cases occurring in 1951. 

Cases with the diagnosis of "hemorrhoids" were chosen as the control 
group because there is no known relationship between hemorrhoids and tuber- 
culosis and because the over all age distribution of these cases was similar 
to that of the study group. 

The percentage of non- Caucasians was slightly higher in the study than 
in the control group (7. 5% as compared to 4. 3%). This difference, however, 
was found to be not statistically significant. The 493 persons in the control 
group contributed 16,073 man-months of exposure while in the study. During 



8 Medical News Letter, Vol. 33, No. 2 



that time, no members of the control group developed active pulmon- 
ary tuberculosis. 

The 268 persons in the study group contributed 8842 man-months of 
exposure. Sixteen members of this group developed active pulmonary 
tuberculosis during the period of the study, yielding a rate of 1.8 cases 
per 1000 man-months of observation. Of these 16 cases, 13 were Caucasian 
and 3 were non-Caucasian. With respect to age, 10 were 30 years of age or 
older in 1951. 

A review of the x-rays of personnel included in the study group re- 
vealed pulmonary lesions which were localized and contained little or no 
calcification. In general, no radiologic difference could be seen between 
lesions diagnosed as "fibrosis, pulmonary, cause undetermined" and those 
diagnosed as "infiltration, pulmonary, cause undetermined. " 

As shown, the members of the study and control groups consisted of 
active duty Naval and Marine Corps personnel with approximately the same 
age and race distribution, who were admitted to naval medical facilities and 
returned to duty in 1951. None had a prior history of active tuberculosis. 
The only gross variable in the two groups, therefore, was the diagnosis 
with which they were returned to duty. All members of the study group had 
been discharged from the hospital with a diagnosis representing an "inactive" 
predominantly noncalcified pulmonary lesion of unknown etiology, while all 
in the control group had been returned to duty with the diagnosis of "hemor- 
rhoids, " 

If the presence of the pulmonary lesions of the study group bore no 
relationship to pulmonary tuberculosis, one would expect that the incidence 
of tuberculosis in the study group would be very nearly the same as in the 
control group. When, however, the actual tuberculosis incidence of 1.8 
cases per 1000 man-months in the study group is applied to the 16,073 man- 
months of observation contributed by the control group during the years of 
study, the expected incidence of cases of active tuberculosis in the control 
group is 29. 1, whereas the actual observed incidence was zero. 

Examination of Navy Statistics for the years 1952, 1953, and 1954 
revealed 1206 new cases of active pulmonary tuberculosis developing in a 
population experiencing 36, 800, 000 man-months of exposure. Applying the 
study group attack rate of 1. 8 cases per 1000 man-months contributed by 
the U. S. Navy during the study, there is an expected incidence of 66, 590 
cases. The actual incidence of 1206 new cases, therefore, represented 
only 1. 8% of the expected cases. 

In a recent study by Wier and Tempel, relapses occurred in 4. 1% of 
a selected group of military personnel with active pulmonary tuberculosis 
who had been treated to the arrested stage and returned to duty by the U. S. 
Army. Analysis of this group was made for those who had been returned 
to duty between 1952 and 1955. Tuberculosis occurred in 5. 9% of the pul- 
monary infiltration and fibrosis cases in the present study group. While, the 



Medical News Letter, Vol. 33, No. 2 



Army group is not completely comparable to the present study group for 
the purpose of statistical analysis, it is interesting to note that the risk of 
developing active pulmonary tuberculosis in this group may have been as 
great or greater than the risk of relapse in the selected Army personnel 
who had been returned to duty after their tuberculosis had been treated to 
the arrested stage. 

Britten determined that, of 79 Naval and Marine Corps personnel 
returned to duty after clinical study in 1949 with diagnoses of pulmonary 
infiltration or fibrosis, 9 developed pulmonary tuberculosis during the next 
3 years. This present study supports these findings which are suggestive 
of a very high incidence of active pulmonary tuberculosis among such cases. 

In view of the demonstrated frequent development of active pulmonary 
tuberculosis in persons "proven" by clinical study to have predominantly 
noncalcified "inactive" pulmonary lesions of unknown etiology, the often 
held concept of the lack of clinical significance of such lesions becomes 
questionable. In all cases in this study developing active pulmonary tuber- 
culosis, the disease was seen to exist in the area of the lung previously 
evaluated. In several cases, the diagnosis of active tuberculosis was made 
within 8 months after the 1951 hospitalization. These facts make it reason- 
able to assume that many of these cases were actually "missed tuberculosis" 
in which the diagnosis could not have been definitely made by means of pres- 
ent clinical and laboratory methods. 

Examination of the clinical records revealed that in every case there 
had been a thorough evaluation made during the 1951 hospital admission. 
Incomplete clinical evaluation did not seem, therefore, to account for the 
abnormally high rate of development of tuberculosis. That it developed at 
such a high rate, indeed, points up the inadequacy of present diagnostic 
armamentarium and, until it is improved, the only means of early detection 
of tuberculous activity in such cases will continue to be frequent follow-up 
examinations over a prolonged period of time. To insure adequate follow- 
up, the establishment of a standardized procedure of examination and a 
central registry of case reports appears to be desirable. 

Because pulmonary tuberculosis is difficult to diagnose in the absence 
of symptoms and bacteriologic confirmation, there is reluctance on the part 
of many physicians to make the clinical diagnosis under these conditions. 
This is understandable, but this study shows that if tuberculous activity is 
to be detected early and its dissemination kept to a minimum, the physician's 
index of suspicion must be high in the case of the "stable" predominantly 
noncalcified pulmonary lesion. 

It is concluded that persons in the U. S. Navy, determined by means 
of present diagnostic methods to have either pulmonary infiltration or fibro- 
sis of unknown etiology, are more likely to have or to develop active pulmon- 
ary tuberculosis than is now generally appreciated. (Captain J. F. Chace 
MC USN, Rockoff, S. D. , M. D. , Hellman, L. P. , B. S. , M. A. , Pulmonary 



10 Medical News Letter, Vol. 33, No. 2 



Infiltration and Fibrosis of Unknown Etiology - The Risk of Developing Active 
Pulmonary Tuberculosis: Arch. Int. Med., 102 : 367-374, September 1958) 

s[e sj: * jjt # * 

Cardiac Asthma 

Cardiac asthma is thought to occur in about 8% of cases of organic 
heart disease. The present report develops the thesis that the management 
of cardiac asthma requires in most instances the disciplines of the cardio- 
logist and the allergist. To do this, current concepts of cardiac asthma 
are presented from the points of view of the cardiologist and the allergist, 
and the problems of diagnosis and management are outlined. 

McGinn and White provided the following vivid description: "Cardiac 
asthma is a name applied to a kind of dyspnea peculiar to organic cardiac 
disease. For this particular condition, it is distinctive and preferable to 
such other terms as pulmonary edema or paroxysmal dyspnea because it is 
truly asthmatic in nature and is fundamentally of cardiac origin. Cardiac 
asthma is paroxysmal, coming on usually in sleep, but at times following 
exertion. An attack quickly rises to a peak, is accompanied by both inspi- 
ratory and expiratory difficulty and frequently by a terrifying sense of suf- 
focation which causes the patient to sit up or to stand erect and even to go 
to the window for air. The attacks last from a few minutes to a few hours 
averaging about an hour and leave the patient in an exhausted condition for 
hours or days. " 

Cardiac asthma is precipitated by acute failure of the left ventricle. 
It is a common feature of syphilitic and hypertensive cardiovascular disease, 
aortic valvular disease, coronary insufficiency, and myocardial infarction. 
It occurs, but is infrequent in cases of mitral stenosis, thyrotoxicosis, and 
other conditions which lead to failure of the left ventricle. Chronic pulmon- 
ary diseases, particularly chronic bronchitis, emphysema, bronchiectasis 
tuberculosis, and carcinoma have been said to predispose to cardiac asthma, 
but on very little evidence. 

The mechanism by which paroxysmal cardiac dyspnea is generated, 
with or without asthma, can be described as follows: When the predisposed 
person falls asleep, the respiratory reflexes become less sensitive, ven- 
tilation is adequate, and there is functional balance between the right and 
left ventricles. The sequence of events leading to an attack of cardiac asthma 
begins soon thereafter. This sequence should be thought of as progressing 
through three stages, namely, the events which precipitate, those which 
maintain, and those which relieve the attack. 

Factors which tend to precipitate an attack are thought to have in com- 
mon the ability to change the cardiopulmonary status from that of the de- 
pression of sleep to the reflex hyperexcitability of the awakening. This, in 



Medical News Letter, Vol. 33, No. 2 11 



turn, is thought to lead to increased ventilation, pulmonary congestion, re- 
duced vital and maximal breathing capacities, and a temporary imbalance 
between the right and left ventricles. The things to which this sequence of 
events have been attributed are: the supine position, resorption of edema 
fluid, increase of venous pressure, a decrease in the concentration of the 
serum protein, a decrease in vital capacity during the early morning hours, 
an accumulation of bronchial mucus, deep breathing, cough, nightmares, 
abdominal distention, constipation, a full bladder, hunger, excessive warmth, 
arrhythmia, outside noises, Cheyne-Stokes respiration, trepopnea, nausea 
and vomiting, decreased coronary flow during sleep in cases of hypertension, 
muscular effort of an attack of noncardiac asthma, and compression of the 
pulmonary veins by the enlarged left ventricle. 

Factors which tend to maintain an attack are said to be the persistence 
of those which precipitated it and the added metabolic demands of the cough 
and strenuous respiratory efforts of the attack. The vicious circle of cough- 
increased ventilatory effort, pulmonary congestion, and cough — leads to 
pulmonary edema or to acute coronary insufficiency and death unless it is 
broken. 

Factors which tend to relieve an attack have been reported to be expec- 
toration of mucus, emptying of the bladder, passage of gas, throwing off the 
bed clothes, and assumption of the upright position. If these factors do not 
produce relief promptly, the physician can relieve the attack by depressing 
the respiratory reflexes and cough, by decreasing the return of venous blood 
from the periphery, by decreasing peripheral vascular resistance, by reduc- 
ing broncho spasm and anoxemia, by increasing the flow of blood in the cor- 
onary vessels, and finally, by improving myocardial efficiency. 

Fortunately, most attacks can be relieved by the administration of 
morphine alone or supplemented by the application of tourniquets to the four 
extremities (bloodless phlebotomy). The efficiency of drugs and other meas- 
ures used for the relief of asthma depends on their ability to increase the 
coronary circulation, to decrease the volume of circulating blood, peripheral 
vascular resistance, hyperventilation, and bronchospasm, and to restore 
the normal function of the left ventricle of the heart. 

Administration of small doses of a 1 : 1000 solution of epinephrine is 
effective in the treatment of cardiac and noncardiac asthma. The sympa- 
thetic nerves are thought to be coronary dilators. Administration of small 
doses of epinephrine relaxes the bronchioles and arterioles, increases the 
flow of blood in the coronary vessels, and increases the functional capacity 
of the left ventricle. 

The role of the allergist has been reempha sized recently in a review 
of 26 cases of cardiac asthma. Several clinical observations were made 
which are thought to have practical value. For example, asthma and heart 
disease may run their courses independently, neither seeming to influence 
the severity of the other. Typical cardiac asthma and typical nonasthmatic 



12 Medical News Letter, Vol. 33, No. 2 



paroxysmal cardiac dyspnea can occur at different times in the same 
patient. An attack of asthma due to other causes may occur in a case of 
cardiac disease in which there is no evidence of heart failure; heart failure 
may occur in a case of asthma in which there is no intensification of pre- 
existing asthma. Mild attacks of cardiac asthma may precede a series of 
severe attacks. A series of mild nightly attacks of cardiac asthma is not 
infrequent. Cardiac asthma may be relieved temporarily by noncardiac 
management including the use of conventional symptomatic remedies for 
asthma. Patients with severe heart disease may often avoid attacks by 
avoiding known allergenic influences. Prompt recognition of the allergic 
or infectious component may provide early protection of the heart from the 
strain of repeated attacks. 

In only 6 of the 26 cases of cardiac asthma studied with the disciplines 
of the allergist and the cardiologist were the patients relieved adequately by 
cardiac therapy alone. The other patients required cardiac plus allergy 
and infection therapy for maximal relief. Eighteen had had asthma due to 
other causes. Twenty -five — all but one — had other manifestations of an 
allergic background. Fifteen had evidence of respiratory infection. All had 
some evidence of heart failure, usually from arteriosclerotic heart disease, 
with or without hypertension. 

The treatment of cardiac asthma is rather routine after the role of 
paroxysmal failure of the left ventricle has been recognized and the other 
noncardiac causes of asthma have been evaluated. Attacks of asthma and 
the underlying heart failure are controlled by the measures described. 
Treatment of allergy consists of the avoidance of offending foods and inhal- 
ants and the injection of extracts of allergens which cannot be avoided. 
Infection should be treated promptly and persistently until cured by specific 
drugs and other appropriate therapy. The paranasal sinuses should receive 
particular attention. (Swineford, O. Jr. , Cardiac Asthma: Postgrad. Med. , 
24 : 577-584, December 1958) 

$ $ $ sjt j|e ifs 

Acute Venous Thrombosis 



The urgency of the physician's concern with acute peripheral venous 
thrombosis (phlebitis) clearly lies in the intimate but unpredictable associa- 
tion between clots in peripheral veins and death from embolization of these 
clots to pulmonary arteries. This article reevaluates the problem of phleb- 
itis on the basis of critical review of published data and of clinical, patho- 
logic and experimental observations. It is believed that a useful frame of 
reference can be derived from this presentation whereby a rational choice 
of therapy can be made in a large majority of clinical situations. 

When thrombosis of a peripheral vein is accompanied by local venous 
distention, tenderness, edema, discoloration, pain, and fever, the diagnosis 



Medical News Letter, Vol. 33, No. 2 13 



is not difficult. Similarly, phlegmasia alba dolens presents little diagnos- 
tic challenge and phlegmasia cerulia dolens — a form of massive venous 
thrombosis that may occasionally be mistaken for acute arterial occlusion — 
is usually easily recognized. However, less extensive venous thrombosis 
may present extraordinary diagnostic difficulties to the most experienced 
clinician. Calf tenderness, pain on dorsiflexion of the foot, slight eleva- 
tion of the postoperative pulse and temperature, and minimal edema of the 
extremity are described by most authorities as the early evidences of deep 
venous thrombosis. Yet, anyone who has seen patients with such symptoms 
knows how difficult they may be to evaluate. Dubious calf tenderness, which 
maybe the only clinical expression of a potentially serious venous obstruc- 
tion, is even less diagnostic and maybe due to orthopedic defects, arthritis, 
myxedema, or myositis. 

Various physical signs or maneuvers have been recommended as an 
aid in the diagnosis of phlebitis. None of these has as yet either stood the 
test of time or been widely accepted. Laboratory tests have been similarly 
unrewarding. Venography which enjoyed a brief period of popularity has 
fallen from general use. The heparin tolerance — although employed in some 
clinics — has not gained wide acceptance. Several investigators have des- 
cribed alterations in known clotting factors in disorders frequently assoc- 
iated with thromboembolic phenomena, but correlations between biochemical 
abnormalities and clinical phlebitis have not been forthcoming. All these 
direct and indirect attempts at diagnosis have failed because there is still 
no reliable test for detecting the prethrombotic, incipiently thrombotic, or 
actively thrombotic state. Furthermore, the severity of the phlebitic symp- 
toms cannot readily be correlated with the likelihood of symptomatic or 
lethal embolization. 

Massive venous thrombosis is often not attended by recognizable pul- 
monary embolism, whereas minimal clinical evidence of a clot in a peri- 
pheral vein can be associated with a fatal obstruction in a pulmonary artery. 
This observation has led to a distinction between "phlebothrombosis" and 
"thrombophlebitis. " In the former, the clot is believed to be the predominant 
aspect of the pathologic process and inflammation of the vein wall a second- 
ary phenomenon; in the latter, the reverse is believed to obtain. It has 
been stated that the hazard of pulmonary embolism is greater in phlebo- 
thrombosis. Actually, the edema, cyanosis, pain, and fever that accom- 
pany some episodes of phlebitis may be related more to the extent of the 
venous obstruction than to actual inflammatory changes in the vein wall. 
In any event, this classification appears to be of dubious prognostic value; 
it may on occasion give rise to a false sense of security. 

Few physicians would deny that venous thrombosis — difficult as it 
may be to diagnose on occasion — is also a common and usually benign 
disease. Such a clinical constellation obviously creates many obstacles 
to defining a practical and consistent therapeutic program. On the other 



14 Medical News Letter, Vol. 33, No. 2 



hand, the unexpected fatality, occasionally in otherwise healthy individuals, 
strengthens the physician's desire to apply a therapeutic program to all 
patients suspected of having venous thrombosis. 

There are three additional facets to the pathogenesis of venous throm- 
bosis that have not received adequate recognition, but that nevertheless 
influence the course of the disease to a profound degree. The first is that 
venous thrombosis has a definite, if indeterminate, incidence of recurrence. 
When a patient is first seen, it is not possible to predict in that individual 
whether a recrudescence may appear, where it may become clinically appar- 
ent, or how extensive and enduring it may prove to be. 

Secondly, venous thrombosis is frequently a focal manifestation of a 
systemic disease. Evidence to support the systemic nature of venous throm- 
bosis derives from patients who have multiple episodes, or phlebitis in dif- 
ferent areas of the body with or without underlying recognizable systemic 
disease. Recurrence of migratory superficial and deep phlebitis in the 
extremities, venous thrombi in visceral and cerebral veins, right atrial 
thrombi, and nonbacterial thrombotic endocarditis are examples. 

Thirdly, the extent to which intravascular thrombi may dissolve spon- 
taneously has not been adequately appreciated. Clinical observations of the 
natural history of venous thrombosis in superficial veins in man clearly 
indicate that obstructed vessels may in time become completely patent. 
Fibrinolytic activity in normal blood has been measured in vitro and spon- 
taneous increases in lytic activity have been observed in a variety of patho- 
logic states. 

All of these considerations relating to the diagnosis and clinical course 
of venous thrombosis indicate the extreme difficulty — in the present state of 
knowledge — of a statistical approach to the clinical evaluation of therapy for 
phlebitis and may, in fact, account for the varying conclusions reached by 
different clinical investigators. 

To construct a workable frame of reference for the clinical manage- 
ment of venous thrombosis within the limits of present knowledge, the 
authors have formulated a general concept that has been helpful to them in 
the treatment of phlebitis. This concept is predicted on the assumed exis- 
tence of a hypercoagulable state and hypothesizes that local vascular injury 
or stasis alone is inadequate to induce clinically significant venous throm- 
bosis. The hypothesis states that individuals with clinically recognized 
intravascular clotting have a state of hypercoagulability as yet not demon- 
strable that predisposes them to thrombosis. Hypercoagulability may be due 
either to known or as yet unidentified alterations in one or more specific 
clotting constituents. These alterations may be induced by the liberation into 
the circulation of altered moieties from gravid uteri, traumatized tissues, 
necrotic foci, malignant neoplasms, or by systemic changes in plasma pro- 
teins. When the balance between clot formation and clot lysis is altered, a 
thrombus can be initiated and potentiated by a degree of stasis that would not 



Medical News Letter, Vol, 33, No. 2 15 



by itself result in clot formation. Finally, hypercoagulability and. vascular 
stasis may be systemic or local, transient, prolonged, or recurrent. With 
this formulation which they have termed "the temporary thrombotic state" 
treatment becomes predicted upon neutralization of the hypercoagulability 
by retarding the deposition of further clot (anticoagulants); the dissolution 
of already formed fibrin (lytic agents); and upon the reduction of stasis 
through the cessation of procedures that favor immobilization and the cor- 
rection of factors, such as shock, congestive failure, and a large peripheral 
venous pool that favor retarded blood flow. 

Because the status of lytic agents is still experimental and the correc- 
tion of shock and congestive failure are well established on other grounds, 
the specific treatment of acute phlebitis is reduced at present to the neutral- 
ization of hypercoagulability by anticoagulant drugs and the decrease in 
vascular stasis by reduction of immobilization and the use of elastic supports. 
Within this formulation, vein ligation and other measures proposed for the 
relief and control of venous thrombosis become ancillary therapeutic tools. 

This review outlines the basis for proposing, and the details for im- 
plementing, a rational and consistent plan of therapy for the management 
of acute venous thrombosis. The authors interpret the entity of venous 
thrombosis as representing a common, frequently systemic disease, clinic- 
ally manifest by focal intravascular coagulation. Concerning this disease, 
the specific etiology is unknown, the diagnostic criteria are crude and 
unsatisfactory and, although the clinical course is usually benign and self- 
limited, it may be unpredictably recurrent and fatal. They have also 
inferred that the difficulties in statistically validating any specific thera- 
peutic measure are, for the present, extremely great and that this problem 
will not be significantly lessened until an accurate test for thrombosis i's 
devised. 

To construct a workable frame of reference for the clinical manage- 
ment of venous thrombosis within the limits of present knowledge, the authors 
have formulated the concept of the temporary thrombotic state. Treatment 
is based upon the neutralization of hypercoagulability by anticogulant drugs 
and upon a reduction of venous stasis by the removal of immobilization and 
a decrease in the size of the peripheral venous pool by elastic support. Var- 
ious aspects of this therapeutic approach are described in detail and illus- 
trated by selected case studies. (Wessler, S. , Deykin, D. , Theory and 
Practice in Acute Venous Thrombosis - A Reappraisal: Circulation, XVIII: 
1190-1207, December 1958) — 

sjt 5}: % # % sje 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

rf^w. *j|C *fi ?JC *fi j*j* 



16 Medical News Letter, Vol. 33, No. 2 

Benign Diseases of the Uteri ne Fundus 

Benign disorders of the uterine fundus, exclusive of infections, make 
up a large part of gynecologic practice and frequently are both misdiagnosed 
and mismanaged. A review of the most common of these conditions should 
serve to clarify their diagnosis and outline their management. 

Mucosal Hyperplasia 

Various synonyms have been applied to this condition in the past. The 
most common ones are glandular hypertrophic endometritis, hemorrhagic 
metropathy, and glandular hypertrophy of the endometrium. A preferred 
term is hyperplasia of the endometrium or mucosal hyperplasia of the uterus. 

Treatment of endometrial hyperplasia depends largely on the age of the 
patient, intensity of bleeding, and degree of anemia. In young women and 
girls, administration of progesterone in a dosage of 50 to 100 mg. per day 
for 3 days at 4-week intervals will decrease the bleeding and may solve the 
problem for an extended period. If bleeding is excessive, androgenic therapy 
may be offered to suppress bleeding in a short time. Testosterone propion- 
ate 50 mg. per day for 4 days, or methyltestosterone, 20 mg. for 5 days 
may serve this purpose without the necessity for hospitalization and dilata- 
tion and curettage. If progesterone and androgen fail to control the bleeding 
or if it is grossly excessive requiring transfusions, dilatation and curettage 
are indicated. 

In middle-aged or menopausal women, the incidence of malignant dis- 
ease of the endometrial cavity is higher and for this reason, one should 
perform dilatation and curettage earlier in the course of the disorder. After 
diagnostic procedures, such as cytologic examination, endometrial biopsy, 
and hysterography have been carried out, one should first perform dilatation 
and curettage for diagnostic purposes and then await its therapeutic effects. 
Use of progesterone as outlined or testosterone, or both, frequently results 
in regression of symptoms and control of the problem. Some workers have 
suggested radiation of the hypophysis as an approach to endometrial hyperplasia, 
but it is not widely used. Partial wedge re section of the ovaries has proved use- 
ful, particularly in the presence of the Stein -Leventhal syndrome. Amenor- 
rhea is more common in the latter condition than excessive menstrual flow. 

Adenomyosis (Endometriosis Interna) 

Synonyms for adenomyosis have included direct endometriosis, adeno- 
myoma, adenomyositis, endometrioma, adenomyohyperplasia, hystero- 
adenosis, fibroadenomatosis, and adenoma endometrioides. The most widely 
accepted term at present is adenomyosis, the definition of which is simply 
ectopic intramural uterine endometrium. 

Hysterectomy is required when the patient has signs and symptoms of 
a degree sufficient to warrant therapy. Hormonal therapy and radiation 
therapy are rather poor second choices. 






Medical News Letter, Vol. 33, No, 2 17 



Myometrial Hyperplasia {Fibrosis Uteri ) 

Terms used in the literature to describe this disorder include chronic 
metritis,, diffuse myoma, fibrosis uteri, and congestion fibrosis. The 
acceptability of these terms is currently under dispute and discussion is 
somewhat limited. 

Treatment of myometrial hyperplasia is hysterectomy because it 
does not respond to endocrine control. The menorrhagia that accompanies 
the disorder may be sufficiently grave to warrant surgical intervention. 

Endometrial Polyp 

Endometrial polyps are frequently associated with endometrial hyper- 
plasia. In the past, they have been called adenoma polyposum. The pres- 
ence of a polyp in the postmenopausal or menopausal period suggests 
excessive stimulation of the endometrial lining and a response of the endo- 
metrium to the stimulus of neoplastic quality. There is a growing feeling 
that endometrial polyps may have the same role in the development of 
endometrial adenocarcinoma as colonic polyps have in the development of 
adenocarcinoma of the colon. Although the incidence of malignancy in 
association with endometrial polyps is appreciably lower than that of car- 
cinoma in association with colonic polyps, one should, nevertheless, keep 
the relationship in mind in managing the condition. Certainly, it suggests 
that treatment might well be more radical than simple curettage and poly- 
pectomy; hysterectomy is being offered more and more when contraindica- 
tions to it are not present. 

Myomas and Fibromyomas 

Myomas and fibromyomas have been defined as benign discrete 
nodular tumors of the uterine wall composed of uterine muscle and fibrous 
tissue in varying proportions and arranged in a disorderly manner. They 
have also been called fibroids and leiomyomas. 

Regular follow-up observation at intervals of 4 to 6 months should 
suffice if uterine fibroids are asymptomatic, small in size, and unrelated 
to infertility. The majority of fibroids may never require therapy under 
these conditions. If the fibroid is moderately large and associated with 
sensations of weight and pressure, pain or disturbed uterine bleeding, 
multiple myomectomy is a procedure which has long been recommended 
for younger women. It is being more widely applied by gynecologic surg- 
eons. Certainly, in the presence of infertility, it is highly desirable to 
remove the fibroids and preserve the uterus. Postmenopausal^, it is 
best to perform hysterectomy for fibroids, particularly if they are the size 
of a 4-month gestation or larger or associated with sensations of weight, 
pressure, and pain, and signs of necrosis or bleeding. 

Lipo ma, Osteoma and Chondroma, Hemangioma and Lymphoma 

Various benign desmoid tumors may develop in the uterus independently; 



18 Medical News Letter, Vol. 33, No. 2 



when associated with uterine sarcomas they are designated as teratoid 
tumors. The great variety and the many minor differences in growth and 
invasive capacity of the mixed tumors make classification difficult. The 
diagnosis is almost always made by the pathologist because the majority 
of these tumors are called "fibroids" preoperatively. All are usually 
treated by hysterectomy. (Kasdon, S. C. , Benign Diseases of the Uterine 
Fundus: Postgrad. Med., 24:464-474, November 1958) 

& $ 3^ & ;{e $ 

Patella in Degenerative Joint Disease 

A detailed description of the patella in degenerative joint disease in 
a large series of cases has not been reported in the literature. The marked 
increase in the number of patellectomies for this disease in recent years 
has made this study possible. 

The patella is a triangular bone, the apex of which points distally; 
this shape is best recognized from the anterior or non-articular surface. 
The posterior surface is divided into an oval articular region above, and 
a non-articular apex below to which the infrapatellar fat pad is attached. 

During the 5-year period, 1950 through 1954, a total of 154 patel- 
lectomies were carried out on 136 patients with degenerative disease of the 
patellofemoral joint. There were 85 female and 51 male patients. All 
patients presented with the complaint of pain. Associated complaints were 
locking, instability, stiffness, crepitus, and swelling. Physical findings 
noted were tenderness, crepitus, effusion, and limitation of motion. The 
histories could be divided into two groups depending on the presence or 
absence of a predisposing condition. An etiologic factor was present in 89 
cases while in the remaining 47 cases, no predisposing condition was found. 

There was a history of trauma in 45 cases. In 13 cases, there was 
an old fracture of the patella, the lower end of the femur, or the upper end 
of the tibia. A torn semilunar cartilage was found at operation in 9 patients. 
The remaining 2 3 patients gave histories of injury, but specific findings were 
not observed. 

A history of recurrent dislocation of the patella was given by 20 patients, 
of whom 18 were female and 2 were male. In 9 cases, dislocation was bilat- 
eral; all 9 patients were female. These patients complained of pain and insta- 
bility or dislocation. The youngest patient was 15 years of age and the oldest 
was 58 years of age; the average age was 35. 

The patellas were available in 109 cases; in 10 patients, both patellas 
were removed, making a total of 119 patellas examined. Each patella was 
anatomically oriented and inspected for the presence of cartilage, degenera- 
tion, eburnation of the articular surface, and marginal hyperplasia. The 
bone was then sectioned horizontally through the center so that a cross section 



Medical News Letter, Vol. 33, No. 2 19 



of the vertical ridge was obtained. The patellas were divided into three 
grades by means of the following criteria: Grade 1, cartilage degenera- 
tion with absence of, or alight, marginal hyperplasia; Grade 2, cartilage 
degeneration with well marked marginal hyperplasia; Grade 3, gross dis- 
tortion in the shape of the patella with eburnation of the articular surface. 
This method of grading is simple and represents the progression of degen- 
erative changes. 

Degenerative disease of the pate llo -fern oral joint is commoner among 
women than among men. In seeking an explanation for this, the known etiolo- 
gic factors must be examined. The three most frequent conditions predis- 
posing to degenerative disease of the patellofemoral joint are trauma, 
obesity, and recurrent lateral dislocation of the patella. 

Trauma is commoner among men; this explains the higher incidence 
of male patients having degeneration of Grades 1 and 2 than degeneration of 
Grade 3. The relative absence of trauma among patients having Grade 3 
degeneration probably reflects earlier surgical intervention in cases in 
which trauma was a predisposing factor. It is interesting to note that the 
incidence of overweight of 30 pounds or more was approximately the same 
for men (7 of 30, or 23%) as for women (15 of 58, or 26%) with degenera- 
tive disease of the patellofemoral joint because this condition is generally 
thought to be commoner among women. 

Recurrent lateral dislocation of the patella is commoner among 
women and it has been shown that dysplasia of the lateral margin of the 
trochlea and of the patella itself is frequently present in these cases. Lat- 
eral subluxation of the patella frequently occurs in advanced degenerative 
joint disease and is commoner among women. 

Patellectomy for degenerative joint disease gives subjective improve- 
ment in a high proportion of patients, particularly those with advanced 
disease. (Haliburton, R.A. , Sullivan C. R. , The Patella in Degenerative 
Joint Disease: Arch, Surg. , 77: 677-682, November 1958) 

$ 3$t $ $ $ j{( 

Broncho -Pulmonary Amoebiasis 

Amoebiasis is mainly and primarily an infection of the colon by the 
pathogenic amoeba, Endamoeba histolytica, but it is also characterized 
by a variable clinical course in which the manifestations caused by the 
occurrence of complications may dominate the picture. 

Invasion of the submucosa may be followed by entry of E. histolytica 
into the radicles of the portal vein and metastasis of the infection to the 
liver. This is followed by amoebic hepatitis or amoebic abscess of the 
liver which is by far the most frequent and important complication. How- 
ever, it has always been known that the lung could be involved and that if 



20 Medical News Letter, Vol. 33, No. 2 



the physician — particularly in an endemic area — is amoebiasis conscious, 
he will be able to find out that amoebic infection is the real cause of many 
cases that would otherwise have been diagnosed as pneumonitis or lung 
abscess of undetermined or unknown etiology. 
Possible routes of infection are: 

1. Primary pulmonary amoebiasis: where endamoeba reach the lung 
by direct embolism from the bowel through the middle and inferior hem- 
orrhoidal veins. In these cases, pulmonary amoebiasis may develop 
independently of hepatic affection and moreover the pulmonary condition 
does not necessarily manifest as suppuration, but it may simulate broncho- 
pneumonia or miliary tuberculosis. Autopsy of such cases revealed firm 
consolidated nodules in the lung in which endamoeba were demonstrated in 
the section. 

2. Secondary pulmonary amoebiasis: This is the commonest variety. 
The condition is associated with, or can be related to, an amoebic liver 
disease. In such cases, infection spreads from the intestines to the liver 
through the portal circulation and then reaches the lung: (a) by direct ex- 
tension through the diaphragm; or (b) by embolization from thrombosed 
hepatic veins to the inferior vena cava to the right side of the heart and 
through the pulmonary arteries to the lungs. 

Recently, cases of lung suppuration have been reported, caused by 
endamoeba gingivalis, a non-pathologic saprophyte which may be aspirated 
into the bronchial tree and produce disease. 

In primary cases, amoeba after reaching the lung produce focal pneu- 
monic consolidation soon followed by necrosis and softening as in the liver. 
With the discharge of the necrotic tissue into the pleural space or through 
the bronchi, a cavity is formed and the lobe undergoes, in part or all, a 
process of consolidation. 

Some have thought that suppuration may commence between the 
diaphragm and the liver or in the base of the lung, but extensive Calcutta 
experience as reported by Roger shows that this is rarely, if ever, the 
case. What happens is that the capsule of the liver becomes fused with the 
diaphragm and the pus escapes into the surrounding tissues to such an extent 
that the primary liver abscess cavity may shrink to the size of the tip of the 
finger and escape observation while a small opening leads into a large secon- 
dary abscess in the base of the lung or between the liver and the diaphragm. 

In most cases, diagnosis was based on evidences obtained from the 
history, the right basal localization of the lung lesions, the character of the 
sputum, and the associated liver condition in the presence of laboratory 
findings that could exclude other possibilities. Diagnosis is more assured 
by failure of other specific remedies and the dramatic responses to emetine. 

Difficulties were met in differentiating between pulmonary tuberculosis 
and pneumonias, including the suppurative forms. The long observation 
without specific treatment or under drugs other than antiamoebic ones without 



Medical News Letter, Vol. 33, No. 2 21 



improvement, compared, with the rapid and dramatic improvement that pro- 
gressed to complete cure once antiamoebic treatment was started, should 
clarify etiological diagnosis. 

Emetine hydrochloride was used in all cases with remarkable success, 
so much so that it is justifiable in doubtful cases as a therapeutic test. The 
general belief is that this is a specific drug and under experimental con- 
ditions destroys E. histolytica in a dilution of 1 : million, although Dobell 
showed that it is lethal to amoeba in culture in a strength of 1 : 5 millions. 
It is reported to be more effective in metastatic lesions than in intestinal 
infection and Manson Bahr advises the following as a full course: 

One grain daily for 7 days, then two grains daily for 4 days, and 

then one -half grain daily for 3 days. 
(Abdel-Hakim, M. , Higazi, A. M. , Cairo, Egypt, Broncho -Pulmonary 
Amoebiasis: Dis. Chest, XXXIV : 607-617, December 1958) 

if. ifi jy. , 5jC 3JC 3jC 

p 
Teflon (Tetrafluoroethylene Resin ) 

(This article was prompted by the repeated rumors during the past 1Z 
months regarding a machinist who reportedly died as a result of smoking 
a cigarette contaminated by Teflon chips. Although the rumor has appeared 
in several publications, a thorough investigation by the Air Force and others 
has proved it to be completely unsubstantiated. The Bureau of Medicine and 
Surgery has received no reports on toxicity from the field involving any un- 
toward effects due to the use of Teflon. ) 

Teflon, because of its unusual engineering properties, has been used 
successfully and without health hazard in a wide variety of naval applica- 
tions. This plastic combines a high degree of chemical resistance, dielec- 
tric strength, and thermal stability. As a result, valve packings, diaphragms, 
and electrical insulation are being fabricated from this plastic for use under 
circumstances where other materials could not be used. 

Recently, some questions have been raised concerning the potential 
health hazard during operations with Teflon. The principal manufacturer 
of this plastic made an exhaustive survey of this subject. The following 
information summarizes the results of this survey and includes data obtained 
through 20 years of experience by the du Pont de Nemours Company, hun- 
dreds of processors and their employees, and thousands of end-item users 
handling this plastic daily: 

1. Teflon should be regarded as an inert material. It can be eaten 
in food, consumed in drink, or worn close to the skin without danger. 
There have been no permanent injuries or deaths in the use of Teflon 
resins. 



22 



Medical News Letter, Vol. 33, No. 2 



2. Decomposition Products at Elevated Temperatures . Some ampli- 
fication may be desirable concerning the use of Teflon resins at higher 
temperatures. Under circumstances where other materials might well 
fail, a number of Teflon resins are designed to operate at temperatures 
over 400° F. While these Teflon items can and do retain their engineer, 
ing properties indefinitely in such use, some minute proportions of de- 
composition products are evolved at a slow rate at 400° F. The rate of 
decomposition increases somewhat if the operating temperature is 
raised to 600° or 700° F. Routine use of mechanical ventilation is con- 
sidered a sufficient precautionary measure. The following ventilation 
rates are recommended: 



Product 



Temperature 



Ventilation Required 



Teflon 1,5, or 7x 



450 F. 
500° F. 
600° F. 
700° F. 



7 cu ft/hr/lb of Teflon 
30 » 
70 M 
600 " 



Teflon 6, or 30 



450° F. 

500° F. 
600° F. 
700° F. 



30 cu ft/hr/lb of Teflon 
80 " 
600 " 
4400 » 



These air requirements represent the volume of air necessary to reduce 
the concentration of the gaseous pyrolysis product (from 1 pound of poly- 
mer) to 1 ppm by weight. The environment on long submergence time 
submarines presents a special case possibly requiring some adjustment 
of this limit and the accompanying air requirements. A separate study 
is being made of this case and will be reported subsequently. 

3. In the few cases reported where excessive amounts of these fumes 
have been inhaled accidentally, they have caused temporary symptoms 
similar to grippe. These symptoms do not appear until 2 to 6 hours after 
exposure and pass off within 36 to 48 hours. 



In summary, the following information may be used as a general guide 
for personnel handling, machining, or heating Teflon: 

1. During the machining of Teflon, dust may be generated. Use local 
mechanical ventilation to control this dust. The use of a coolant is also 
recommended because it permits higher cutting or grinding rates and 
simultaneously keeps the dust concentration to a low level. 

2, If Teflon resins are heated for extended periods in the 400° to 
600° F. range, minute quantities of decomposition products are evolved. 



Medical News Letter, Vol. 33, No. 2 23 



Therefore, adequate mechanical ventilation should be provided when work- 
ing with Teflon at temperatures greater than 400° F. 

3. Smoking should be prohibited in areas where Teflon is being fabri- 
cated in order to minimize the possibility of contaminating the pipe or 
cigarette with Teflon dust. 

(Indust. Toxicology Section, OccMedDispDiv, BuMed) 

^j ;|; :'fi ^e s}: if 

Beryllium and Berylliosis 

Beryllium perforins heroic functions in hundreds of everyday products 
even though its total annual production is measured in pounds, A little 
beryllium goes a long way, especially in the alloys which account for most 
of its consumption. Beryl is the single industrially significant beryllium - 
bearing mineral. The small size of the beryllium ion favors its diffusion 
as a minor constituent in numerous minerals and discourages the formation 
of high-concentration beryllium minerals. 

The principal uses of beryllium stem from the discovery in the 1920's 
that the addition of only 2% of beryllium to copper forms an alloy six times 
stronger than copper. Beryllium -copper alloys stand up at high tempera- 
tures, have great hardness, show resistance to corrosion, do not spark, 
and are nonmagnetic. They are used in the critical moving-parts of air- 
craft engines and in the key components of precision instruments, mechani- 
cal computers, electrical relays, switches, and camera shutters. 

The ill effects on workers who handled beryllium compounds were 
first observed in the United States when a worker employed in processing 
beryllium ores died in 1940. By 1946, the hazard that threatened beryl- 
lium workers developed an alarming new aspect of the disease produced. 
Long after exposure had ceased, 17 cases of chronic beryllosis were re- 
ported in persons previously engaged in the manufacture of fluorescent 
lamps. Most of the cases reported up to that time had been acute attacks 
arising during exposure to beryllium compounds. 

The cases of delayed or chronic illness clearly implicated beryllium 
itself as the poison. The principal distinction between the various beryllium 
compounds now appeared to be merely their relative solubility in the body 
fluids. The acid-forming compounds are the most soluble and produce im- 
mediate illness. The chronic form of berylliosis is distinguished from the 
acute form chiefly by the delay between exposure to beryllium and the onset 
of symptoms. 

As yet, the biochemistry of beryllium poisoning is little understood. 
The ion of the metal, dissociated from the oxide or salt in solution with the 
body fluids, appears to be the active principle. It is known that the chem- 
ical reaction of beryllium ions in the body invariably involves a hydroxide 



24 Medical News Letter, Vol. 33, No. 2 



group (OH) attached to a benzene ring. Such, phenolic hydroxide groupings 
are found in the amino acid tyrosine which in turn undergoes metabolic 
transformation to such compounds as adrenalin which react with beryllium 
ions. In the test tube, beryllium inhibits the action of many enzymes. In- 
jections of tiny amounts of its compounds in experimental animals cause 
massive damage to the cells of practically every organ with which the com- 
pounds come in contact. Similarly, in human victims, upon autopsy, lesions 
are found scattered throughout the organs of the body as well as in the lungs. 
Beryllium poisoning is now accepted as a general disease and it is recog- 
nized that the patient's condition is worse than the lung picture suggests. 

Examination of the lumps and nodules that form in the tissues suggests 
that beryllium can cause the growth and proliferation of cells. This suspicion 
has been supported by the discovery that beryllium may induce cancer in ex- 
perimental animals. Lung and bone cancer have been induced by intravenous 
injection of beryllium compounds; therefore, beryllium may be a factor in 
the genesis of certain cases of human lung cancer. 

Although little is known about the toxicity of beryllium, investigators 
have made one significant finding which already facilitates diagnosis and may 
lead to the discovery of an effective treatment. Patients invariably exhibit 
a kind of allergic response to beryllium compounds. It would seem, there- 
fore, that beryllium must combine with protein in the body to form an antigen. 
The antigen stimulates the formation of beryllium -specific antibodies. As a 
result, in all cases of active berylliosis, a small amount of any beryllium 
compound placed on the skin produces a local allergic reaction. This "patch 
test" is now a valuable aid in the diagnosis of beryllium poisoning. That 
beryllium forms compounds with protein suggests that the logical approach 
to treatment is to look for a way to tie up beryllium chemically so that it 
can no longer react with substances in the body. 

Can the beryllium hazard be controlled? Is it possible to work with 
beryllium compounds in safety? The answer is a somewhat qualified "Yes. " 
The problem reduces itself to one of good industrial housekeeping which 
means keeping the levels of beryllium low. But how low is low? One impor- 
tant factor to be taken into account is that different forms of the same beryl- 
lium compound may have radically different degrees of toxicity depending 
upon particle size as well as solubility. On the basis of extensive tests, the 
Atomic Energy Commission in early 1950 concluded that all known cases of 
the acute disease could be attributed to air concentrations of soluble salts in 
excess of 100 micrograms per cubic meter, and that when the air level ex- 
ceeded 1000 micrograms of beryllium, nearly everyone developed acute 
beryllium poisoning. To minimize the risk of the chronic disease, on the 
other hand, the Atomic Energy Commission found it necessary to recommend 
a limit of 2 micrograms per cubic meter. The strictness of this standard can 
be appreciated when it is realized that the corresponding limits for dusts of 
other metals, such as lead, mercury, arsenic, and cadmium range from 



Medical News Letter, Vol. 33, No. 2 25 



100 to 500 micrograms per cubic meter. As to the air in the neighborhood 
of a beryllium plant, the recommended limit is 1/100 of a microgram per 
cubic meter. To the best knowledge, no cases of beryllium poisoning have 
appeared in or around plants which have adopted these rigid standards. 

The story of beryllium highlights the whole problem of occupational 
disease in the present era. Advances in technology now develop so rapidly 
that the rare material of yesterday becomes the widely used material of 
today. The beryllium mishaps teach the lesson that the harmlessness of a 
material cannot be taken for granted; a new material must be regarded as 
harmful until proved otherwise. Industrial medicine must provide safe 
working conditions before harm results; public health agencies must see 
that the public is not exposed to fumes from industrial processes until safe 
tolerances are known. {Schubert, J., Beryllium and Berylliosis: Sclent. 
Am., 199_: 27-33, August 1958) 

sjc jje $ >Je ajc Hf 

Cataracts and Ultra High Frequency Radiation 

Radar and communication installations are making use of increasing 
amounts of power. As a result, military and civilian populations may be 
exposed to larger doses of radio frequency energy. Such exposures will be 
to the body as a whole. The frequencies used probably will range from the 
ultra-high-frequency band at a few hundred megacycles per second to the 
microwave band at several thousand megacylces per second. 

There is no doubt that microwave radiation has produced cataracts 
in animals. In these experiments, intense radiation was applied locally 
to the eye. The consequences of local irradiation may have some practical 
importance in human beings because microwave radiation is used thera- 
peutically about the eye. There is one reported case of cataracts in a 
human being allegedly due to microwave irradiation, but this probably can- 
not be accepted as proved. In this reported case, the radiation intensity 
reaching the eyes was difficult to estimate. Moreover, the morphologic 
changes in the lenses were nuclear cataracts and not what one expects with 
radiation. 

The objective in the present study was to determine whether or not 
cataracts in animals might result from exposure of the whole body to radia- 
tion at frequencies similar to those used in some high-power installations. 
The immediate concern was with a frequency in the range of 400 megacycles. 
Particular interest lay in comparing the dose which produces cataracts with 
that which causes death. 

Only one similar series of animal exposures appears to have been made 
with comparable frequencies in the ultra-high-frequency band. No cataracts 
were observed in any of these animals, although they received radiation in 



26 Medical News Letter, Vol. 33, No. 2 



near lethal amounts. However, the paucity of reported observations directed 
to the problem of eye damage and the practical importance of the problem 
warranted further study using present methods of quantitative investigation. 

Material and Methods 

Most of the exposures were carried out in a waveguide system, but 
some were made in "free space. " The term "free space" must be inter- 
preted with some reservation. In an attempt to duplicate actual exposure 
conditions, the test animals were contained in a small lucite box placed in 
the vicinity of the radiating antenna. Adult male albino rabbits were used 
exclusively. 

Results of Eye Examination 

Examination of the eyes showed nothing which could be called a cataract. 
Punctate opacities were occasionally seen in the posterior subcapsular cor- 
tex of the rabbit lenses, but these were often seen prior to irradiation and 
were as frequent in the control group as in the irradiated group. They were 
of such small dimensions that they might well have been seen on one exam- 
ination and overlooked on the next. 

Comment 

Previous investigators applying local microwave irradiation to the eyes 
of rabbits have reported the threshold dose for cataracts to be in the range 
of 120-220 imw/cm. . Finding that ultra-high-frequency radiation at an inten- 
sity of 60 mw/cm. 2 is not cataractogenic is consistent with this, but further 
comparison is probably unwarranted in view of the different frequencies used. 
However, one might expect that the cataractogenic dose would be higher with 
ultra-high-frequency radiation than with microwave radiation which gives 
rise to heating in the region of the lens. 

There is no direct way of comparing the susceptibility of human and 
rabbit lenses to this form of irradiation. However, with local microwave 
irradiation the cataractogenic dose for monkeys has been found to be higher 
than that for rabbits. Until evidence is presented to the contrary, these 
results with rabbits probably provide an assessment of the cataractogenic 
possibilities in human beings. 

Summary 

Ultra-high-frequency radiation (at 468 megacycles per second) was 
repeatedly applied to rabbits in doses near the lethal level. This radiation 
was distributed over the whole body. No cataracts developed following the 
exposures. (Cogan, D. G. , et al, Cataracts and Ultra-High-Frequency 
Radiation: Arch. Indust. Health, 18: 299-302, October 1958) 

(OccMedDispDiv, BuMed) 

£ 2gt jfe $ ♦ ♦ 



Medical News Letter, Vol. 33, No. 2 27 

Prolonged, and Recurrent Industrial Dermatitis 

Contact dermatitis occurs more frequently than any other disease 
arising from employment. A wide variety of causes can produce occupa- 
tional dermatoses, but primary irritant and sensitizing chemicals are 
responsible for the majority of cases. Generally, the diagnosis of a con- 
tact dermatitis can be made by carefully observing the type of lesions 
present and the areas of involvement. The causes can usually be found by 
taking a detailed history, with special attention being paid to the time of 
onset and the substances to which the individual has been exposed both at 
work and elsewhere, and by properly performing the patch test and such 
other tests as may be necessary. A close observation of the course of the 
disease is no less important. Cure or alleviation is accomplished by elim- 
inating contact with the irritant or sensitizing substance if possible, by 
proper local therapy, the use of protective clothing, by job change, and 
sometimes by the discontinuance of work for varying periods. 

Most cases of occupational dermatitis are easily managed by proper 
diagnosis and appropriate treatment. However, in some cases, dermatitis 
recurs repeatedly or fails to heal after conventional therapy. The reasons 
for this — in the opinion of the Committee on Occupational Dermatoses — 
are (1) incorrect dermatological diagnosis, (2) failure to recognize the 
cause, (3) failure to eliminate the cause when recognized, (4) improper 
treatment, (5) failure to recognize secondary infections, (6) lack of per- 
sonal cleanliness by the worker because of poor cleansing facilities and 
cleansing agents, (7) placement of dermatitis -prone individuals on poten- 
tially hazardous jobs, (8) development of cross -sensitivity, (9) develop- 
ment of multiple reactivites, (10) malingering, and other such factors as 
active focus of infection, presence of fungus disease, and presence of 
constitutional skin disease. (Council of Industrial Health, The Problem of 
Prolonged and Recurrent Industrial Dermatitis: J. A. M. A. , 168: 516-520, 
October 4, 1958) (OccMedDispDiv, BuMed) 

>[e t[i iji % JpJc >Jc 

Noise - Is It a Health Problem? 

The permanent hearing loss produced by extended exposure to certain 
occupational noises constitutes a serious health problem. The solution to 
this problem lies in active programs of hearing conservation. Hearing 
conservation is primarily a medical responsibility. The importance of the 
physician's recognition of his role in meeting the threat to health cannot be 
overemphasized. 

The physician must acquaint himself with the current knowledge of 
the relations of hearing loss to noise exposure. Misconceptions about the 



28 Medical News Letter, Vol. 33, No. 2 



hazardous effects of noise are widespread. Auditory effects of noise expos- 
ure and non-auditory effects are frequently related without justification. 
For example, the fact that a noise produces annoyance does not — contrary 
to popular belief — mean that exposure to that noise will necessarily produce 
a hearing loss. The annoyance caused by noise is a highly individual phe- 
nomenon and, as such, is not easily measured or predicted. The fact that 
a noise produces annoyance does not mean that it is bad for health. 

The total amount of hearing loss produced by noise exposure depends 
on more variables than was originally thought. Before the diagnosis of 
noise-induced hearing loss can be made, the physician must have adequate 
information about (1) the over all sound pressure level of the noise, (2) the 
way the energy in the noise is distributed among the various frequencies 
present, {3) the typical pattern of daily exposure to the noise, and (4) the 
years of expected work life in the noise. Answers given by the patient 
cannot be assumed to be reliable and the physician must make the neces- 
sary effort to obtain the pertinent information from reliable sources. 
(Glorig, A. Jr. , Summerfield, A., PhD., Noise - Is It a Health Problem? 
J. A.M. A., 168:370-376, September 27, 1958) (OccMedDispDiv, BuMed) 

****** 
New Convening Dates for Pest Control Course 

New convening dates have been announced for the basic course in 
Disease Vector and Economic Pest Prevention and Control offered at the 
Disease Vector Control Center, NAS, Jacksonville, Fla. The new schedule 
extends the course into a basic four-week course and offers the course every 
other month instead of quarterly. 

Convening Dates for Calendar Year 1959 

2 March 1959 to 28 March 1959 

4 May 1959 to 30 May 1959 

6 July 1959 to 1 August 1959 

7 September 1959 to 3 October 1959 

2 November 1959 to 29 November 1959 

The course is open to all active duty officer and enlisted personnel. 
Military civilian employees engaged in pest control activities are also 
eligible for this course and are urged to attend. Billeting and messing 
facilities are available at NAS, Jax. , for both military and civilian person- 
nel attending course. Attendance quotas are allocated and may be requested 
by communicating directly with the Officer in Charge, Disease Vector Con- 
trol Center, Jacksonville, Fla. 



Medical News Letter, Vol. 33, No. 2 29 



Aviation Seminar 

The Fourth Annual Research Reserve Seminar in Aviation Medicine 
will be held at the U. S. Naval School of Aviation Medicine in Pensacola, 
Fla. , for a two-week period commencing 9 March 1959. This seminar 
sponsored by the Office of Naval Research in conjunction with the Naval Air 
Training Command and the School of Aviation Medicine, is open to Reservists 
of all services who have an interest in scientific and operational problems 
of Naval Aviation and its role in the conducting of modern warfare. Applica- 
tion for attendance at this seminar should be made through regular service 
channels. (ONR) 

sje s}: ijc $ 4 s ♦ 

Board Certifications 



American Board of Dermatology and Syphilology 
LTJG Julius L. Danto MC USNR (Inactive) 
CAPT Clyde W. Norman MC USN 

American Board of Ophthalmology 

LT William F. Hoyt MC USNR (Inactive) 
CDR Roger Stevenson MC USN 

American Board of Otolaryngology 

LT James M. Anthony MC USNR (Inactive) 

American Board of Pediatrics 

LTJG Alexander S. Fitzhugh, Jr. MC USNR (Inactive) 

American Board of Surgery 

LT John H. Dawson, Jr. MC USNR (Inactive) 

CDR Donald W. Robinson MC USN 

LT Shirley E. Townsend MC USNR (Inactive) 

American Board of Surgery & Thoracic Surgery 
LTJG Josiah Fuller MC USNR (Inactive) 

American Board of Urology 

LT Robert T. Braman MC USNR (Inactive) 



ijc s)c lie sj; :|c ijc 



30 Medical News Letter, Vol. 33, No. 2 



From the Note Book 

1. At the 1958 Meeting of the New York Academy of Sciences, the title 
of Fellow of the New York Academy of Sciences was conferred upon 

Dr. Howard T. Karsner, Medical Research Advisor to the Surgeon General, 
Election to Fellowship in the Academy is a signal, distinguished honor, con- 
ferred upon a limited number of Members who, in the estimation of the 
Council, have done outstanding work toward the advancement of Science. 

(TIO, BuMed) 

2. CAPT C.J. Gell MC USN was presented the Melbourne W. Boynton Award 
for Space Medicine at the American Astronautical Society's Annual Meeting. 

(TIO, BuMed) 

3. CAPT C. E. Wilbur MC USN and CAPT M. W. Ballenger MC USN have 
been elected Chairman and Secretary, respectively, of the Joint Committee 
on Aviation Pathology for 1959. The Committee, which includes medical 
officers of the military services of the United States, the United Kingdom, 
and Canada, held its fifth business meeting at the Armed Forces Institute 
of Pathology on December 11, 1958. (TIO, BuMed) 

4. CAPT L,. J. Pope MC USN has assumed command of the U. S. Naval 
Medical School, NNMC, Bethesda, Md, , relieving RADM C. B, Galloway 
MC USN who reported to the Bureau of Medicine and Surgery as Assistant 
Chief of Research and Military Medical Specialties. (NNMC) 

5. Two cases of pericarditis due to tularemia are reported. Tularemic 
pericarditis may occur as the only apparent complication of tularemia, 

a fact of importance in diagnosing certain cases of this serious illness. If 
treated with streptomycin, tetracycline derivatives, or chloramphenicol, 
the prognosis is similar to benign sero-fibrinous pericarditis. (Dis. Chest, 
December 1958; C.W. Adams, M. D. ) 

6. Eight cases of Ehlers-Danlos' syndrome (hyper -elasticity and fragility 
of the skin combined with hyperlaxity of the joints) occurring in the same 
family are reported. The pedigree suggests a dominant mechanism of 
heredity of this disease. (Arch. Derraat. , December 1958; K. O. Husebye, 
M.D. , K. Getz, M. D. ) 

7. The ultimate place of amphotericin B in the treatment of the deep mycoses 
must await both a longer observation of treated patients and comparison with 
more recently developed therapeutic agents. It is evident that this antifungal 
antibiotic is highly effective initially against North American blastomycosis, 
histoplasmosis, cryptococcosis, and sporotrichosis when given intravenously. 



Medical News Letter, Vol. 33, No. 2 



31 



In general, it is a useful agent against most infections with yeast-like 
fungi. (Arch. Int. Med., December 1958; J. H. Seabury, M. D. , H. E. 
Dascomb, M. D. ) 

8. The dashboard femoral fracture is an injury unique to high-speed auto- 
mobile accidents. Thirty fractures of this type are reported, analyzed, 

and evaluated as to end result. The fracture conformation is characteristic 
and the etiological forces are constant. Great care must be exercised so 
that hip and knee injuries will not be overlooked. (J. Bone & Joint Surg. , 
December 1958; COL S. J. Ritchey MC USA, et al. ) 

9. The clinical and hemodynamic findings in 30 patients with congenital 
aortic stenosis are summarized and the potentially serious nature of this 
defect is emphasized. The use of left heart catheterization in the precise 
assessment of the severity of the obstruction and in the detection of sub- 
valvular stenosis is described. (Circulation, December 1958; A. G. Morrow, 
M. D. , E.H. Sharp, M. D. , E. Braunwald, M. D. ) 

10. A method of processing arterial segments by the freeze-drying technique 
is presented with a description of the equipment and the steps involved. (Arch. 
Surg., December 1958; J. M. Erskine, M. D. ) 

11. This article reports the authors' experience in scleroderma correlating 
the electrocardiograms with the clinical, physiopathologic, and morphologic 
findings. (Am. Heart J. , December 1958; J. Escudero, M. D. , E. McDevitt, 
M. D. ) 

12. The evaluation and management of some minor injuries of the eye are 
discussed in Postgrad. Med., December 1958; K. L. Roper) 



* 



-;c 



IN MEMORIAM 



CAPT James P. Bowles MC USN (Ret) 

CAPT Louis E. Tebow MC USN 

CAPT Henry C. v\Teber MC USN (Ret) 

CDR Russell J. Trout MC USN (Ret) 

LCDR LaSalle H. James DC USN (Ret) 

LCDR Frederick R. Haselton Sr. MC USN (Ret) 

LT Frank L. Titsworth MSC USN (Ret) 

LTJG Edward H. Meeteer MSC USN (Ret) 

LTJG Paul E. Robinson Sr. MSC USN (Ret) 

CWO Henry D. Mullins MSC USN (Ret) 



24 December 1958 

29 October 1958 

30 October 1958 
5 November 1958 

23 November 1958 

24 October 1958 
4 November 1958 
II November 1958 
29 November 1958 
23 September 1958 



32 Medical News Letter, Vol. 33, No. 2 

Recent Research Reports 
Naval Dental Research Facility, NTC, Bainbridge, Md. 

1. Survey of Dental Health of the Naval Recruit. IX. Relation of Father's 
Occupation. NM 75 01 26.04, 24 October 1958. 

2. Survey of Dental Health of the Naval Recruit. X. Relation of the Father's 
Income. NM 75 01 26.04, 30 October 1958. 

Naval Medical Research Institute, NNMC, Bethesda, Md. 

1. The Influence of Dietary Inorganic Sulfate on Growth and Dental Caries 
in Rats. NM 75 01 00. 01. 04, 15 July 1958. 

2. Studies on Mineral Metabolism in the Rat. II. Effect of Casein Level 

of the Diet on the Formation of Calcium Citrate Urinary Calculi. NM 75 01 00 
.01.05, 15 July 1958. 

3. Host Influences on Some Haemosporidian Parasites. Lecture and Review 
Series. No. 58-5, 15 July 1958. 

4. Further Studies of Drug-Resistant Strains of Rickettsia Prowazeki. 
NM 25 05 00. 02. 02, 21 July 1958. 

5. Studies on the Contractile Proteins of Muscle. II. Polymerization Reactions 
in the Myosin B. System. NM 01 01 00. 02. 06, 4 August 1958. 

6. Radiomimetic Effect of Triethylenemelamine on Reproduction in the Male 
Rat. NM 01 02 00. 03. 02, 5 August 1958. 

7. Some Changes in the Biological Characteristics of Colonized Anopheles 
Quadrimaculatus Say . NM 52 07 00.01.02, 6 August 1958. 

8. Toxicological Study of Hydraulic Fluids Cellulube 550A, Kolube 220, and 
Houghto-Safe 1055. NM 53 01 00.03.01, 8 August 1958. 

9. Histological Evidence of the Mechanism of Resistance to Challenging 
Cercariae of Schistosoma Mansoni. Lecture and Review Series No. 58-6, 
8 August 1958. 

10. Normal Rat Serum as a Growth Factor for Trypanosoma Lewisi. Lecture 
and Review Series No. 58-7, 8 August 1958. 

11. Polarographic Observations on Bivalent Metallic Ion- Acetylcholine- 
sterase Interaction. NM 02 02 00. 01. 09, 14 August 1958. 

12. An Experimental Study of Ammonium Intoxication. NM 72 02 00. 01.02, 
22 August 1958. 

13. Electro-Encephalographic Correlates of Ammonium Carbonate Intoxication 
in the Rat. NM 72 02 00.01.03, 9 September 1958. 

Naval Medical Research Unit No. 3, Cairo, Egypt 

I. Ticks (Ixodoidea, Ixodidae) Parasitizing Lower Primates in Africa, 
Zanzibar, and Madagascar. NM 52' 08 03.3.03, January 1958. 



Medical News Letter, Vol. 33, No. 2 33 

2. Notes on African Haemaphysalis Ticks. IV. Description of Egyptian 
Populations of the Yellow Dog -Tick, H. Leachii Leachii (Audouin, 1827) 
(Ixodoidea, Ixodidae) NM 52 08 03.3.02, January 1958. 

3. Needle Biopsy of the Lung. NM 72 04 03. 1, March 1958. 

4. The Hares of Egypt. NM 52 08 03.7.02, April 1958. 

5. On Zone Electrophoresis of Human Parotic Saliva in Starch Gels. NM 75 
02 03.2(1), April 1958. 

6. The Ticks (Ixodoidea) of Iraq: Keys, Hosts, and Distribution. NM 52 08 
03. 3.04, May 1958. 

7. The Ticks (Ixodoidea) of Egypt. NM 52 08 03. 3. 07, May 1958. 

8. Histopathological Study of Liver Biopsies in Pulmonary Tuberculosis in 
Egypt. NM 52 13 03.1.01, November 1958. 

Naval Medical Research Laboratory, Sub marine Base, New London, Conn. 

1. The Measurement of Dextrose in Standard Solutions with Dreywood's 
Anthrone Reagent and the Klett- Summer son Photoelectric Colorimeter. 
(A statistical evaluation and simple microprocedure). Report No. 294, 
NM 24 01 20. 02. 01, 10 April 1958. 

2. Memorandum Report No. 58-9. Some trends in the Submariner Selection 
Data for 1957-1958. NM23 02 20.01.01, 30 July 1958. 

3. Memorandum Report No. 58-8. Report on a Direct-Current High-Pressure 
Xenon Arc. NM 22 01 20. 01. 03, 6 November 1958. 

Naval School of Aviation Medicine, NAS, Pensacola, Fla . 

1. Vocal Pitch Changes: Effects on Intelligibility Test Scores. Report 
No. 76, SubtaskNo. 1, NM 18 02 99, 30 April 1958. 

2. Effect of Restricting Information in the Verbal Conditioning Situation on 
Extinction. Report No. 1. NM 14 02 11-11, 1 May 1958. 

3. A Note on Peer Nominations as a Predictor of Success in Naval Flight 
Training. Report No. 14, SubtaskNo. 1, NM 16 01 11, 23 May 1958. 

4. Calculation of Product -Moment Correlations Matrices with the IBM 604 
Calculating Punch. Report No. 26, Subtask No. 1, NM 14 02 11, 1 July 1958. 

5. Evaluation of Certain Visual and Related Tests. IV. Size Constancy. 
Report No. 4, SubtaskNo. 6, NM 14 01 11, 15 July 1958. 

6. Spontaneous Pneumothorax in Flight - A Case Report and Brief Review 
of the Literature. Report No. 3, SubtaskNo, 1, NM 19 01 11, 17 July 1958. 

7. Reflex Ocular Torsion in Healthy Males. Report No. 47, Subtask No. 1, 
NM 17 01 11, 30 July 1958. 

(Listing of Research Reports will be continued in an early issue) 

% % fjc jjt % % 



34 Medical News Letter, Vol. 33, No. 2 




DENTAL UW.I SECTION 



Dental Corps Featured in January Journal 

The January issue of tne newly named Journal of Oral Surgery, Anes- 
thesia, and Hospital Dental Service departed from its long established pub- 
lication procedure by devoting the entire issue to articles by authors who 
are associated with a single source. The nine authors of seven scientific 
articles and seven authors of five case reports are all officers of the Dental 
Corps of the U.S. Navy. It is anticipated, therefore, that the January 1959 
issue will be recorded as the United States Navy issue. Although none of 
the thirteen reports deal with conditions specific to the Naval Service, that 
fact makes them more valuable to dentists in civilian practice because the 
conditions described are common to both civilian and military patients. 

The titles of the editorial, articles, and case reports and the names 
of their Navy Dental Corps authors are: 

Asepsis in Minor Oral Surgical Procedures: A Reevaluation 
(Editorial) - Rear Admiral Ralph W. Taylor DC USN 

Blue ( Jadassohn-Tieche) Nevus: A Previously Unreported Intraoral 
Lesion - Commander Henry H. Scofield DC USN 

Management of Oral Surgical Problems Complicated by Maxillary 
Sinus Involvement - Captain Donald E. Cooksey DC USN and 
Captain Robert A. Middleton DC USN 

Treatment of Zygomatic Fracture-Dislocations 
Captain Walter W. Crowe DC USN 

Use of the Foley Catheter in Supporting Zygomatic Fractures - 
Captain John P. Jarabak DC USN 

Useof Freeze-Dried Bone for Treatment of Nonunion after Surgical Correc- 
tion of Mandibular Prognathism - Captain Raymond F. Huebsch DC USN 

Cervicofacial Actinomycosis: A Postextraction Complication - Captain 
Theodore A. Lesney and Commander Kimble A. Traeger DC USN 



Medical News Letter, Vol. 33, No. 2 35 



Diagnosis of Oral Keratotic Lesions - 
Captain. Louis S. Hansen DC USN 

Case Reports 

Management of Subcondylar Fracture - 

Commander Anthony P, Giammusso and Captain W. Basil Johnson 

DC USN 

Mandibular Protrusion - 

Captain Harold G. Green DC USN 

Mixed Tumor of Floor of Mouth in a Seven- Year Old Child - 
Captain Robert A. Colby and Captain Roger G. Gerry DC USN 

Simultaneous Carcinoma of Upper and Lower Lip - 
Captain Frederick T. Wigand DC USN 

Carcinoma in a Healing Alveolus after a Dental Extraction - 
Captain Wilbur N. Van Zile DC USN 

$ jje * * * * 

Information Required from Essayists and Clinic ians 

Dental officers who accept invitations to present essays or clinics 
before an organization or meeting are reminded of the necessity to comply 
with Article 6-34, Manual of the Medical Department. This directive re- 
quires the submission of pertinent information to the Bureau of Medicine 
and Surgery, and to Commandants of the Naval Districts involved at the 
earliest practicable date prior to the meeting. Timely submission of the 
information will afford the Bureau and District Dental officers an oppor- 
tunity to give appropriate publicity to the event. 

# >[c jjt >jc >[e sjt 

ADA Relief Fund Reaches $63, 695 

Contributions to the ADA Relief Fund reached $63,695 on November 
30, 1958, as reported by Dr. H. R. Bleier of Milwaukee, Chairman of the 
ADA Council on Relief. The Navy Dental Corps has contributed 51%, or 
$560. 95, of its $1100 quota. Dr. Bleier urges that contributions be sent 
as soon as possible to: ADA Relief Fund, 222 East Superior St. , Chicago 
11, 111. He states: "The cause is highly deserving and the need is great. " 

* % * $ * # 



36 Medical News Letter, Vol. 33, No, 2 




RESERVE SECTION 



Tropical Medicine in the Field 
NavPers 10995 - 1958 E dition 

During World War II, tropical diseases caused more casualties in 
many areas than did enemy action. Such diseases have long been a serious 
deterrent to successful military operations in the tropics. The added exper- 
ience of the recent wars has naturally heightened military interest in tropical 
medicine and especially in the application of the many recent advances in 
medicine to the treatment of tropical diseases. 

This correspondence'course will be of special interest to all Medical 
Corps officers. The purpose of the course is to provide a concise guide in 
tropical medicine not only for the physician practicing in the tropics, but 
also for those in temperate zones who may be encountering tropical diseases 
of servicemen and others returning to the United States after a tour of duty 
in the tropics. The course is based upon A Manual of Tropical Medicine by 
Mackie, Hunter, and vVorth; it covers the essential practical aspects of epi- 
demiology, diagnosis, treatment, and prophylaxis of the more important 
tropical diseases. 

Laboratory analysis plays an especially helpful and dramatic role in 
the diagnosis of diseases in indigenous personnel in tropical areas where 
the language barrier may make a provisional diagnosis difficult. Another 
factor to be considered is that natives of tropical areas may react to local 
diseases with symptoms very unlike those exhibited by non-natives. The 
text material stresses the importance of military medicine and special effort 
has been directed to the condensation of information essential for the Armed 
Forces, the clinician, the field worker, and the student of tropical medicine. 

The course consists of twelve (12) objective type assignments and is 
evaluated at thirty-six (36) Naval Reserve promotion and/or non- disability 
retirement points. Naval Reserve personnel who previously completed the 
correspondence course, "Tropical Medicine in the Field, " NavPers (none), 
edition 1950, will receive additional credit for the completion of course 
NavPers 109951 

Applications for this course should be submitted via applicant's command 
to the Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. (Attn: Correspondence Training Division). 

sjc >;= • ;Jt >\c s[i >£ 



Medical News Letter, Vol. 33, No. 2 37 



Som e Pointers on Promotion Point 
Credit for Residency Training 

1. Reserve Medical officers not on active duty may receive promotion 
point credit for completion of approved residency training. 

2. One promotion point for each semester hour or equivalent thereof 
may be credited not to exceed 12 per fiscal year. To be creditable, residen- 
cy training must have been completed in present grade since 1 July 1950. 
For residencies completed prior to 1 July 1957, promotion points are credit- 
able as of 1 July 1957. Residency training completed in subsequent fiscal 
years may be creditable on a yearly basis as of 30 June of the fiscal year that 
each year's training is completed, 

3. Requests for promotion point credit must be submitted by the indi- 
vidual Reserve officer to the Officer in Charge, Reserve Officer Recording 
Activity, Omaha, Neb. , forwarded via the Chief, Bureau of Medicine and 
Surgery. 

4. Each request must be accompanied by a certification from the insti- 
tution or activity where the training was taken showing the type and inclusive 
periods in which enrolled. Credit can only be given for training completed 

in increments of 12 months and ca nnot be credited in advance of any gi ven 
date. 

5. The Chief, Bureau of Medicine and Surgery will evaluate the train- 
ing received and by endorsement certify the number of promotion points and 
forward individual requests to RORA for appropriate administrative action. 




i&I^(h PREVENTIVE MEDICINE SECTION 




DDT Resistance in the Human Body Louse 

The failure of DDT to control the human body louse was first observed 
in Korea in 1950 - 1951, Laboratory studies conducted by H. S. Hurlbut 
established that these lice had a measurable degree of physiological resis- 
tance. G. W. Eddy confirmed these findings and pointed out that, although 
all samples of lice tested were then highly resistant to DDT, the suscep- 
tibility of Korean lice to DDT prior to the use of this insecticide -was not 
known; that is, there was no base line for comparison in that area. Similarly, 



38 Medical News Letter, Vol. 33, No. 2 



C. H. Barnett and E. C. Knoblock reported that human body lice collected 
from vagrants in Tokyo were distinctly resistant to DDT and they presumed 
that these lice had not previously been exposed to DDT — at least for several 
months prior to testing. 

It is impossible to ascertain from these reports whether this resis- 
tance was natural or was acquired by selection through the use of DDT. On 
the other hand, it is an established fact that DDT had been used extensively 
during a typhus outbreak in Japan and Korea in 1945 - 1946 and that DDT 
was subsequently available to the occupation forces. 

Starting with a field-collected strain of lice, K. Yasutomi was able 
to select in three generations a resistant strain capable of withstanding 
residual deposits of 60 to 70 times as much DDT as the original strain. 

This report covers, in part, the results of a cooperative project by 
the Communicable Disease Center, Public Health Service, U. S. Department 
of Health, Education, and Welfare, Savannah, Ga. , and the laboratory of the 
Entomology Research Division, Agricultural Research Service, U.S. Depart- 
ment of Agriculture, Orlando, Fla. , designed to determine some of the fac- 
tors involved in the resistance of DDT of the original Korean strain of body 
lice which has been maintained under DDT selection at that laboratory for 
several years. 

A conspicuous feature of the results obtained with topical application 
is the extremely slow rate of absorption of DDT through the louse cuticle. 
Owing to the particularly tough and oily nature of this cuticle, solvents 
such as ethanol, acetone, or benzene proved unsuitable for topical applica- 
tion. Some higher alcohols were too toxic, and several vegetable and min- 
eral oils, including Risella oil, were found unsatisfactory. 

Because no marked differences in absorption were found between resis- 
tant and susceptible lice, rate of penetration of DDT may be ruled out as a 
defense mechanism of the resistant strain. Also, it is evident that only 
minute amounts of DDT were needed internally to cause complete mortality 
of the susceptible strain. 

Greater differences in tolerance for DDT are clearly demonstrated 
in the feeding experiments. The fact that resistant lice could tolerate 100 
p, p. m. of DDT in the blood with minimum mortalities, whereas 10 p.p. m. 
were lethal to more than 50% of the susceptible lice, indicates the presence 
of an intrinsic biochemical difference and strengthens the conclusion that 
penetration of DDT through the cuticle is not an important factor. 

The metabolism tests in vivo indicated that the ingested DDT was al- 
most completely metabolized by the resistant strain, whereas little or no 
degradation of DDT occurred in the susceptible strain. While a concentra- 
tion of 10 p. p.m. of DDT produced 53% mortality of the susceptible lice in 
24 hours, the limit of sensitivity of the analytical methods did not permit 
the use of lower concentrations in order to ascertain whether susceptible 
lice could metabolize sublethal doses of DDT. 



Medical News Letter, Vol. 33, No. 2 39 



Although the metabolite obtained from the in vivo metabolism of DDT 
by the resistant strain has not been positively identified, certain of its pro- 
perties have been clearly defined. On the basis of solubility characteristics, 
both before and after nitration, DDE (dichlorodiphenyl dichloroethylene) 
might be ruled out as a possible metabolite, although it is conceivable 
that conjugation with a protein or a lipotrotein might sufficiently alter the 
solubility of DDE to form a more polar conjugate. 

In limited experiments, using topical applications of DDT to the same 
strain of resistant lice mentioned in this report, C, W. Kearns reported the 
presence of a metabolite that responded in the same manner as DDE to the 
Schechter-Haller colorimetric test. On the other hand, tests in vitro, using 
lice homogenates, showed no evidence of the existence of a mechanism com- 
parable to that found in the resistant house fly, Kearns stated, however, 
that owing to difficulties encountered in extraction and removal of interfering 
materials, these findings were not conclusive. 

It is worth noting that none of the synergists tested in combination with 
DDT appreciably increased the mortality of the resistant strain. These find- 
ings are in agreement with results of M. M. Cole who reported no increase 
in the mortality of DDT-resistant lice exposed to DDT : DMC (1, l-bis-{p- 
chlorophenyl) methyl carbinol) and DDT :MR-60 (bis-(p-chlorophenyl) chloro- 
methane) combinations. Other investigations have demonstrated that certain 
DDT-synergists, including those mentioned above, interfere with the enzyma- 
tic conversion of DDT to DDE in house flies both in vivo and in vitro. These 
results strengthen the assumption that the metabolite from lice is not DDE 
and that the mechanism of DDT-breakdown is different from that found in flies. 

Experiments in vitro distinctly showed that homogenates and acetone 
po.vders of both resistant and susceptible lice are capable of metabolizing 
DDT at an approximately equal rate. By analogy with the enzyme DDT- 
dehydrochlorinase which is found in DDT-resistant house flies, but not in 
any measurable quantity in susceptible strains, one might infer that enzyma- 
tic breakdown of DDT in lice is a natural phenomenon, i. e, , that all strains 
of lice, both resistant and susceptible, possess a "hidden resistance potential" 
to DDT in the form of a detoxifying enzyme system whose action on DDT is 
interfered with by some other unknown biochemical factor which is operative 
in the susceptible strain, but is bypassed in the resistant strain. This bypass 
mechanism which is accentuated through selection pressure with DDT would 
then allow the resistant louse sufficient survival time to enable the enzyme 
to neutralize the absorbed insecticide. In order to arrive at a logical con- 
clusion, these hypotheses must be tested further by investigating several 
other susceptible and DDT-resistant strains from various localities. 
(Perry, A. S. , Buckner, A, J. , Biochemical Investigations on DDT-Resistance 
in the Human Body Louse, Pediculus hum anus hum anus: Am. J. Trop. M. Hyg. , 
7: 620-626, November 1958) 



40 



Medical News Letter, Vol. 33, No. 2 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 



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